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Protocol Based Approacment in Severe Sepsis: One Year

Experience

Zuhal Karakurt, Tülay Yarkın, Nalan Adıgüzel, Gökay Güngör,

Özlem Soğukpınar, Eylem Acartürk

Süreyyapaşa Chest Diseases and Thoracic Surgery Teaching Hospital, Respiratory Intensive Care Unit, İstanbul, Türkiye

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AimAim

We evaluated the efficacy of protocol based We evaluated the efficacy of protocol based approach including the interventions approach including the interventions mentioned above (except APC) in the patients mentioned above (except APC) in the patients with severe sepsis admitted to our respiratory with severe sepsis admitted to our respiratory intensive care unit (RICU) in one year period.intensive care unit (RICU) in one year period.

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Methods

Study design: Prospektive clinic study Place: Tertiary Teaching Hospital

10 bed medikal ICU Study period: 1 January 2006 – 31 December 2006 Patients: ARF patients with severe sepsis stayed

more than 24 h in ICU Evaluations: patients’ characteristic and nutrition,

cathetarization, mechanical ventilation were recorded.

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MethodsPatients with severe pepsis:

SIRS:systemic inflamatuar response sendrome

1.Fever: < 36 or >38 C

2. Heart rate > 90/m

3.Respiratory rate >20 or PaCO2 <32mmHg

4.WBC: < 4000 or >12000 or 10% band

Severe Sepsis: Sepsis with organ disfunction (hypoperfusion, changed mental status, oliguria etc).

Sepsis Shock: Sepsis related hypotension refractory to fluid resusitation ( need vasopressor to gain optimal arterial tention)

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Methods

Sepsis Protocols: Early Goal Directed Therapy: fluid resussitation (MAP>65mmHg) and emprical

antibiotics Low Tidal Volume: 6ml/kg Tight Glucose Control: Insulin infusion to obtain blood glucose equal 80-

140mg/L Moderate Dose Steroid: Methyl prednisolon 20mg 3 times daily for 7 days

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ResultsResults

176 patients

119

severe sepsis

38 (49)

Septic shock

29death

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ICU mortality rate: 24%ICU mortality rate: 24%

Death unrelated to sepsis: 17 (%14)

1) Myocardial Infarction

2) Lung cancer

3) IPF (end stage)

4) Serebro vascular accident (SVA)

Death related to sepsis: Death related to sepsis:

12 (%10)12 (%10)

1) Resistant pathogen1) Resistant pathogen

2) Inappropriate empirical 2) Inappropriate empirical antibioticsantibiotics

3) Multiple organ failure 3) Multiple organ failure

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Results of Sepsis Protocols

Fluid resucitation

SF Albumin Vasopres İnsülin Steroid Low Vt

Survivors

n:90 (%)

22

(24%)

16

(17%)

17

(18%)

17

(18%)

11

(12%)

25

(27%)

Nonsurvivors

n:29 (%)

19

(65%)

14

(48%)

19

(65%)

11

(37%)

7

(24%)

9

(31%)

p 0.001 0.002 0.001 0.03 >0.05 >0.05

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ResultsResults

Survivors

n=90

Nonsurvivors

n=29 p

APACHE II 19±6 24 ±6 0.002

CRP 30 ±32 61 ±58 0.06

Septic shock, n 17 (18%) 21 (72%) 0.001

Mechanical ventilation, n (%)

55 (61%) 17 (58%) > .05

Central catheter, n (%) 25 (27%) 17 (58%) 0.004

TPN, n (%) 32 (35%) 23 (79%) 0.0001

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Risk factors for sepsis related Risk factors for sepsis related mortalitymortality

pp O.R.O.R. C.I.

Number of organ Number of organ failure failure <0.000<0.000

114.54.5 2.3-9.02.3-9.0

Number of Number of central venous central venous cathetercatheter

0.020.02 5.65.6 1.2-261.2-26

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Outher, year

Sepsn

Shockn

EGDT

Vt TDG

APC

steroid

Septic Shock

Mortality

Controlmortalit

y

Shapiro NICCM, 2006

116

79 + - + + + 20 % 29 %

Lin SMShock,2006

241

224 + - - - - 50 % 67 %

Nquven HB AEM, 2006

-- 24 + - + + + 45 % --

Trzeciak SChest 2006

-- 22 + ? - + + 18 % 43 %

Karakurt Z

119

49 + + + - + 10 % (24)

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Sepsis related mortality reducing studiesSepsis related mortality reducing studies

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ConclusionsConclusions

Mortality rates in severe sepsis Mortality rates in severe sepsis varied from 28% to 50% in the varied from 28% to 50% in the literature. literature.

In this study, we demonstrated In this study, we demonstrated that sepsis related mortality can be that sepsis related mortality can be decreased by using protocol based decreased by using protocol based management including EGDT, LVT, management including EGDT, LVT, TGC and MDS in such patients.TGC and MDS in such patients.